Dear Lisa,
We can not get our 4 1/2 yr old grandson to go to potty for any bowel movements. He will hide in a corner and go in his pants. He will get on his bed and go in his pants. He does not care where you are at when he goes in his pants. You can punish him and it is like he does not care. I will tell him how embarrassing it is and that does not bother him either. Can you please help and tell us what to do or try next? I have run out of ideas or suggestions from others. His sister is very embarrassed about the situation.
“Need help in Virginia”
Dear “Need Help In Virginia”,
In order for a child to be ready to potty train, there are a few developmental milestones that need to be reached. First a child needs the fine and gross motor skills to pull down their pants and sit on a potty. They also need the physical strength and coordination to remain on the potty and the abdominal strength to push a bowel movement out.(1) Secondly, a child requires the intellectual ability and attention span needed to be able to sense the need to go to the bathroom and understand what will happen if they don’t go on the potty. (1,2) A child also needs to reach the level of speech development that is required to communicate to adults that they need to go. (2)
Besides being physically and developmentally ready, children need to be psychologically ready to use the potty or toilet. Children need to be able to adjust to change, they need the desire to want to please their parent or caregiver, they need the desire to conform to what is expected and they need to overcome any fears that they may have related to toileting. (2)
I can understand your concern because your grandson is 4 ½ years old and still not potty trained. From your description it sounds like he does not have a desire to go in the potty and just goes to the bathroom when and where he wants to. This must be frustrating for you and his whole family.
The normal age for potty training ranges from 2 to 4 years old. It can take 6 months to train a child to go to the bathroom in the potty. (1) If a child is over 4 years and cannot achieve this goal in six moths, an evaluation and treatment by a health care professional is needed.
The first step in approaching this problem is to have your grandson evaluated by his Pediatrician. This evaluation should include a complete history and physical examination in order to rule out any physical causes for your grandson’s inability to potty train. There are some childhood health conditions, such as a tethered spinal cord that prevents a child from feeling the sensation to go. As as a result, a child with this problem has difficulty controlling his bowel movements. Other conditions such as a developmental disorder, Autism or Attention Deficit Disorder may also interfere with the process of potty training. (1) Children with medical conditions such as Cerebral palsy or Autism can benefit from the expertise of specialists. An Occupational Therapist or a Preschool Handicap Program may be needed to assist children with these conditions.
Once all physical causes for the inability to potty train are ruled out; family dynamics and psychological problems should be addressed. Control issues may be the source of the inability to potty train in some circumstances. (1) Control issues may develop in a child who is seeking attention because of a change in family dynamics such divorce, sibling rivalry or a new baby entering the home. (1) A child can use their refusal to potty train as a source of getting attention.
For families in this situation, special alone time with the child can help. Scheduled time alone with the child, reading a book, going for a walk or playing a game can offer positive ways for a child to get the attention that he is seeking. It is important to be consistent and schedule alone time on a daily basis. When scheduling alone time, limit setting may be necessary for children who struggle with this issue. An effective way to set limits is to use an egg timer. (1)
In some cases, difficulty potty training can be complicated by constipation, stool withholding or painful stools. (1) It is important to first establish a successful stooling pattern, before attempting to potty train. Dietary modifications or use of laxatives may be necessary in order to maintain a soft regular stool pattern that facilitates training. If this is an issue with your grandson it would be important to discuss this with his Pediatrician.
You did mention that punishing your grandson did not make a difference. Punishing a child for soiling his pants is not recommended. (1,2) Accidents are best approached in a matter of fact manner. This may be very difficult to do, especially in a case where a child takes such a long time to potty train and does not seem to listen. Praising your grandson for good behavior, such as sitting on the potty, telling you that he needs to go, being cooperative with changing can help boost his confidence level and give him the tools that he needs to know that he is capable.
For children who refuse to comply at all, room restriction may be an option. This approach is successful in children with established stool patterns including a soft bowel movement around the same time each day. First, the caregiver tells the child that he is expected to use the potty. Thirty minutes before the expected time of the bowel movement the child should be confined to one room with toys, but no television. The child must stay there until he poops in the potty. (1) Caregivers are encouraged to come and go in and out of the room.
Once the child uses the potty then he is free for the rest of the day. If the child has an accident, the caregiver should not punish the child or reprimand the child, but instead just clean up the mess in a matter of fact way. This approach takes two days on average before a child starts using the potty. (1)
Many of the preschoolers that I took care of refused to use the potty because they were dependent upon or attached to a Pull up or diaper. If this is the case you can open the diaper, stretch it out and place it inside the potty by clicking it under the removable rim. Your child can then sit on the potty and see the diaper inside. This way your child can have the control of going in the diaper, but the diaper is actually inside the potty.
Once a child starts to go on the potty on a regular basis, then the caregiver can cut a hole in the center of the diaper before putting it into the potty. When this is done, some of the stool will fall into the potty when the child goes to the bathroom. Each week cut a larger and larger hole in the diaper until you reach the point that there is only a small piece of the diaper in the potty. This approach helps children who have difficulty "letting go" of the diaper.
Changes in the family dynamics, stress, and history of sexual abuse are all additional potential reasons for a child not potty train. (1) If a child is approaching 5 years old and still will not potty train after all physical reasons are ruled out , a consultation with a Child Psychologist may be necessary.
I wish you success in your endeavor and your grandson the confidence and self control he needs to accomplish this very difficult task!
If you are interested in reading other stories on the Pediatric Advice Website addressing these issues:
Toilet Training
Withholding Stool
Constipation
References:
(1)Howard BJ. Toileting Problems of Young Children. Audio-Digest Pediatrics. 2000.46(02).
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:219-221.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice Updated Daily
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